bridges, connecting two worlds

Proprietary and Confidential

Building Bridges, Connecting Two WorldsArizona Telemedicine Program

Southwest Telehealth Resource Center


Health Choice Arizona Tribal Liaison

Holly FigueroaHopi/Ohkay Owingeh

Sipaulovi VillageSun Clan

Pronouns She/Her


Learning Objectives

• Gain understanding of Tribal Cultural Awareness

• Review Telehealth In Indian Country

• Discuss Cultural Norms• Tips for engaging tribal members, tribal communities, or tribal partners


Tribal Sovereignty

My recommendation would be ensure your agency honors and

respects the sovereignty of all the Tribal Nations and

their diverse cultures in your respective service areas


• Arizona Tribal members have choice of where they are able to access physical and behavioral health care services.

• Care coordination is facilitated in a confidential manner that recognizes the importance of Tribal Sovereignty & Nation Building, and meets the needs of tribal members through the development of individualized tribal agreements

Access to Care for Native Americans

American Indian Member

Indian Health Service

Tribal/Regional Behavioral Health

Authority

Tribal 638VA

Other Tribal

Providers


Cultural Awareness


Tribal History

= ReservationLands

1492Arrival of Columbus

1790ForcedInland

1830IndianCountry

1860ImmigrationStampede

1890Vanquished

2090Indian Country?


Formation of Federal Policy & Its Impact

Pre‐Colonization

First Peoples lived autonomously in their homelands

1492

Arrival of Columbus

US Constitution1788

The US Constitution

written for and by white men.

Indian Removal Act 1830

This authorized the president to grant unsettled lands west of the Mississippi in exchange for

Indian lands within existing state borders.

General Allotment Act of 1887

Also known as the Dawes Act, this law allowed for the

president to break up reservation land, into small allotments to be parceled out to individuals

Indian Reorganization Act

of 1934

Designed to effect an orderly

transition from federal control to

native self‐government.

Indian Termination Act of 1953

American Indian tribes will be disbanded and their land sold. A companion policy of “relocation”

moves Indians off reservations and into urban areas.

Indian Civil Rights Act of 1968

granted Native American people, for the first time, full access to the United States Bill

of Rights.

Self Determination & Indian Education Act

of 1975

Congress declares its commitment to the maintenance of the Federal Government’s unique and continuing

relationship with and responsibility to the Indian

people

American Indian Religious Freedom

Act of 1978

protects the rights of Native

Americans to exercise their

traditional religions

Native American Graves Protections & Repatriation Act of

1990

Provides for the ownership or

control of Native American cultural items (human remains and

objects) excavated or discovered on Federal or tribal

lands.

Executive Order 130841998

Tribal Consultation & Collaboration


Impact of European Contact• Introduction to

• Alcohol• Guns• Disease (Measles, tuberculosis, pneumonia)• Sugar• Homophobia

• Cultural Genocide• Children forced to cut their hair• Change their names• Forbidden to speak their Native language• Forbidden to Practice their culture• Physical Abuse• Isolation• Starvation• Female and male children sexually abused by priests • Sterilization of women and girls


Historical Trauma

Historical traumas, including forced relocations and cultural assimilation, numerous broken treaties, and other social, economic, and political injustices, continue to affect AI/AN communities in significant ways. AI/AN health disparities are inherently tied to historical and current sociopolitical experiences.

Indian leader, George Gillette, breaks down during the 'taking ceremony' of Indian lands in Congress in 1949


Colonization and Oppression: Outcomes

• Post Traumatic Stress Disorder (PTSD)

• Fear/Anxiety

• Mistrust

• Low self‐esteem

• Decreased Faith in Traditional Medicine


Today’s Native Americans

Today’s Native American lives are likely to have been influenced by the history of oppression, repressions, intergenerational anger and grief, experienced since North American was colonized by Europeans.


The Tribes


Tribal Sovereignty• Tribes are Sovereign Nations

• Treaty Tribes have a Nation to Nation relationship with the US Government

• States do not have jurisdiction on tribal lands

• Movements towards Tribal Self‐Governance

• Tribes make and enforce their own laws


Federally Recognized Tribes574 Federally recognized American Indian/Alaskan Native tribes


Cultural Competency & Cultural Considerations


How Does Culture Impact Care/Service?

Health is a cultural construct based on cultural issues and beliefs about the nature of disease/illness and the human body. Therefore, should be considered in the

delivery of services.


Philosophies• Cultural Competence emphasizes the need for health care systems and providers to be aware of and responsive to patients’ cultural perspectives and backgrounds. Ensuring that family preferences, values, cultural traditions, language and socioeconomic conditions are respected.

• Cultural Competence is a skill that can be taught, trained, and achieved and is often described as a necessary and sufficient condition of working effectively with diverse patients.

• Cultural Humility involves entering a relationship with another person with the intention of honoring their beliefs, customs and values. It entails an ongoing process of self‐exploration and self‐critique combined with a willingness to learn from others.

• The concept of Cultural Humility, de‐emphasizes cultural knowledge and competency and places greater emphasis on lifelong nurturing and self‐evaluation and critique.


Impact of Cultural Difference

Potential Cross‐Cultural

Differences

Food

Religious Beliefs

End of life decision making

Western medicine approach

Expectations of health

professionals Pain expression & management

Traditions

Beliefs about symptom origins

Family involvement & gender roles


Tribal Challenges• AI/AN have the highest rate of poverty of any other racial group in the nation at 2X the national poverty rate.

• AI/AN lack health insurance 3X than whites.• Funding issues• Limited familiarity with AI/AN policies• Complexities/logistics


Tribal Mental Health• AI/AN experience serious psychological distress 1.5 times more than the general population

• The three common mental health disorders are major depression, post traumatic stress disorder, alcohol dependence.

• PTSD is 2 to 3 times the national rate.• The suicide rate is 3 to 6 times higher among AI/AN. This is one of the greatest health disparities faces by AI/AN youth.

Source: National Institute of Health


Tribal Barriers to Services

• Economic barriers

• Lack of awareness about tribal community issues

• Communication styles

• Stigma associated with mental illness/services

• Mistrust

• Transportation

• Phone Accessibility

• Discrimination

• Lack of awareness and knowledge of tribal communities in the service area

• Lack of understanding of tribal structures

• Justice System• Health Care System


Tribal Strengths & Protective Factors• A strong identification with culture• Family• Connection with the past• Traditional health practices• Adaptability• Wisdom of elders


Culturally Sensitive Approaches & Response• Increase awareness of tribal issues & topics

• Tribal justice system• Tribal infrastructure• Mental health • Physical health

• Conduct stigma awareness training with tribal community gatekeepers/champions

• Educate providers and stakeholders on cultural norms• Better integration of traditional healing and spiritual practices


Telehealth and Tribes


History

• 1973 Indian Health Service partnered with NASA and Lockheed Martin to provide telehealth to the Tohono O’odham Nation


Telehealth in Indian Country• IHS collaborates with tribal leaders to deploy telemedicine services that respond to patient and community need. Telehealth service availability varies by location, but may include specialty services such as behavioral health, dermatology, endocrinology, wound management, and rheumatology.

• IHS has two national telehealth programs and numerous regional telehealth programs.

• The IHS‐Joslin Vision Network Teleophthalmology Program is dedicated to preventing diabetes‐related blindness.

• the IHS Telebehavioral Health Center of Excellence (TBHCE) Telebehavioral Health Program is to provide, promote, and support the delivery of high‐quality, culturally sensitive telebehavioral health services to American Indian/Alaska Native people.


Telehealth Implementation Considerations• Rural Tribal Communities

• Awareness of geographic isolation• Workforce shortages• Resistance to new technology

• Systematic review• Involving tribal leaders & patients during program development

• Diffusion of Telehealth• Importance on training and hiring clinical staff from the local community.

• Consider engaging Community Health Representatives (CHR) to assist patients


Telehealth Lessons from COVID‐19

• Provide meaningful increases to the IHS budget for telehealth, electronic health records and health information technology (IT) infrastructure development

• Permanently Extend Waivers under Medicare for Use of Telehealth

• Enact Certain Sections of the CONNECT to Health Act• Ensure that Medicare reimburses IHS and Tribal providers for telehealth services at the IHS All‐Inclusive Rate or “OMB Rate”


Telehealth Resource

• Patient Cisco Meeting Experience via YouTube ‐ available off the IHS Network

• Healthcare Provider Cisco Meeting Experience via YouTube ‐ available off the IHS network

• Considerations for Tribal and Urban Programs Wanting to Transition to Telebehavioral Health

• Guidance for IHS Behavioral Health Programs Wanting to Transition to Tele‐Based Services

• IHS Telebehavioral Health Center of Excellence

• IHS Teleophthalmology Program

• Step‐by‐Step Guide for Setting Up Telebehavioral Health Services https://www.ihs.gov/sites/telebehavioral/themes/responsive2017/display_objects/documents/tbhcetoolkit2018.pdf


Helpful Tips


Tribal Variance• It is importance to be mindful that every tribe may have diverse beliefs

• Variances between tribes may include but are not limited to• Values• Traditions/Spirituality• Social/Family Structure• Languages

• NEVER ASSUME• Never assume that every tribal member holds the same beliefs and ideals

• Use the background information to ask culturally sensitive, informed questions

• DON’T GENERALIZE


Spiritual Beliefs• Traditionally Native American spirituality is nature based

• Beliefs:• Supreme creator (possibly other spiritual figures)• Humans = body + mind + spirit• Every part of nature (living and non‐living) is sacred and has a spirit

• Each spirit existed before the actual body was created, and will exist after the body dies

• Spirits (with or without a body) are part of everyday life• Each tribe has specific beliefs for the afterlife


Native Healing Philosophy & PerspectivesNative Communities have been doing these practices from a mainstream perspective but we have adapted them to be more cultural appropriate for Tribal Customs and Values.

• Sweat Lodge• Smudging• Story Telling• Family and Community Connection• Herbal Remedies• Drum• Talking Circle• Tribal Song/Dance


• Extended family are VERY important

• Depending on the tribe, families could include:• Actual blood relatives• Clan members• The community as a whole

• Depending on the tribe, descent, the passing of authority, goods, knowledge or traditions, can be either:• Matrilineal (through the mother’s family)• Patrilineal (through the father’s family)

Social Structure


• Community

• Culture

• Loyalty and support of extended family are highly valued• Extended family is often involved in decision making

• Respect for the aged is expected

• Cooperation, interdependence, and collectiveness

• Nature, and its preservation, is of utmost importance

• Rituals and traditional ceremonies may be a part of everyday life

Values


Cultivating & Fostering Relationships

• Native American cultures are highly diverse and each community will have its own set of expectations, beliefs, and practices

• Building a relationship with a tribal community/partner takes commitment and consistency.

• Commitment• Humility• Listening• Don’t make promises you can’t keep• Sense of Humor• Consistency• Have a good contact person• Present/Talk with Tribal Leadership• Meet Regularly• Meet IN PERSON• Be flexible


Engaging Native Americans in TreatmentRecognizing Individuality and Cultural Connection:

• Relationship building / mindful of stereotypes• Welcoming environment• Boundaries • Humor• Importance of personal stories• Explanation of the process• Importance of peer support • Family and community involvement – kinship / clan structure• Seamless collaboration within the system – referral and care coordination

• Respect right to choose where they receive healthcare


Conclusion

Learning about and accepting diversity can improve your interpersonal effectiveness and

increase your personal and professional opportunities.


AsqualiThank You

Holly Figueroa(928) 214‐2169

[email protected]://www.healthchoiceaz.com/providers/tribal‐

program/

bridges, connecting two worlds

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